496803412-12-2-2021-21-AS-SHAN-C9BTNB-20211202135227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803412
Report Date: 12/02/2021
Date Signed: 12/02/2021 01:52:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SUNRISE OF PETALUMA		FACILITY NUMBER:	496803412
ADMINISTRATOR:	LAYTON, NATHAN		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DR		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 79	DATE:	12/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nathan Layton - Executive Director		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/02/2021 at 9:00 AM License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection visit of the facility. LPA was welcomed by front desk concierge and checked in with electronic temperature log in. Executive Director Nathan Layton was called by concierge and left a meeting upstairs arriving shortly after. There are a total of 40 Assisted Living and 39 dementia residents in memory care. There are 7 residents currently on Hospice. LPA toured the facility at approximately 9:30 AM with Executive Director (ED) Nathan Layton; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 12/09/2020. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 10/12/2021. Every resident apartment has an individual smoke detector in addition to hard wired, and smoke detectors were found to be in working order. LPA observed Carbon monoxide detectors that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 117 degrees F and 119.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 10 of 10 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. Facility serves residents without dementia in the memory care - Reminiscence part of the facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations (2 day supply of perishable & 7 day of nonperishable). Toxins were inspected and are located in multiple locked maintenance/storage rooms throughout the facility. All resident’s bedrooms have lighting & appropriate furnishings. Exit doors have auditory alert system that was functional at time of inspection. Medications are kept and centrally stored in upstairs locked wellness office and when delivering medications a locked medication cart is used. There is a daily activity schedule for residents posted on the wall: entertainers playing the piano & guitar as well as a baking club and exercises every morning, bingo, and scenic drives in the bus. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SUNRISE OF PETALUMA	FACILITY NUMBER: 496803412
	VISIT DATE: 12/02/2021

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Infection Control:

Facility has submitted a mitigation program plan that has been approved, on 3/29/2021. All staff and visitors check in with the electronic temperature log and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in the second floor storage closet, laundry and in one of the few rented storage supply units across the street. Facility has a 30-day supply of medication for residents. Staff had all PPE training required on file as well have been N95 Fit Tested.

In addition, facility has designated areas for visitors in a private dinning room and other areas which are being allowed for visits. Residents also have available zoom, facetime, and telephone calls when contacting with family members and others and assistance if needed. Disaster Drills are conducted quarterly with the last being 09/28/2021.

LPA reviewed Licensing Information System (LIS) with ED who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA discussed new PIN 21-44 that went into effect Nov. 30, 2021 regarding all staff needing to be fully vaccinated or have exemption letter on file with results of their weekly surveillance testing.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 12/10/2021 to RPRO:

LIC 308 Designated

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

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